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A 46 year old female complains of increased polyuria and polydipsia along with muscle weakness and abdominal cramps. She has been smoking 2 packs a day for the past 24 years along with history of alcohol intake for the past 22 years. She is a also a known diabetic who is on metformin. On physical examination, the PMI is found at the sixth intercostal space. Further examinations reveal normal neck veins without any peripheral edema. Her blood pressure recording comes out as 148/98 mmHg. Standing from behind and examining reveals a mild scoliosis. She was taking licorice in the past, but denies taking them recently. Her lab works are pending, but which will be the most specific lab finding that will correlate with the patient’s clinical condition? +
A 6-year-old boy is brought to the clinic for partial seizures. The patient was born via normal vaginal delivery to consanguineous parents. The parents state that the patient had delayed speech and motor skills compared to his peers when he was young. They also report that he has autistic-like behavior and suffers from mental retardation. On physical exam, the patient has a long face with everted ears. Cardiac auscultation is remarkable for a mid-systolic click followed by a systolic murmur that is best appreciated at the the 5th left mid-clavicular intercostal space. The physician suspects a genetic disease and orders genetic testing to confirm his suspicion. Which genetic disorder best characterizes this patient's condition? +
A 2-year-old African-American girl is brought to the emergency department by her father. The girl is continuously crying in pain. On physical examination, the patient's extremities are warm, edematous, and tender to palpation. X ray of the patient's hands and feet reveals tissue swelling but no bony abnormalities. Further questioning reveals that the child is the product of a consanguineous marriage. The patient is then admitted for management with intravenous saline and analgesic agents. Which of the following genetic alterations is most likely responsible for this patient’s condition? +
A 7-year-old boy is brought to his pediatrician's office for progressive bilateral deafness. Family history is significant for a similar condition among multiple family members. Physical examination is remarkable for subcapsular posterior lens opacities, peripheral coalescing retinopathy, and high-tone sensorineural deafness. The physician suspects the patient's condition is caused by a genetic disease. Genetic testing results demonstrate a mutation in the ''COL4A5'' gene. Which test is most likely to reveal abnormal findings during further work-up of this patient? +
A 76 year old female is admitted to the hospital because of altered mental status. She has a history of diabetes, hypertension, osteoporosis and mild depression. At home, she was on metoprolol, rosiglitazone, hydrochlorthiazide and sertaline. She also takes alendronate on a weekly basis. She has been on these medications for a number of years. Before admission, she was living independently in her apartment and was able to perform nearly all day-to-day activities. It was her daughter who found her in her apartment, very confused in her bed. On examniation, you see a drowsy, frail, elderly women in no acute distress. Her temperature is 36.7 C, blood pressure is 130/70 mmHg, pulse is 102/min and respiartions are 16/min. Her oxygen saturation is 97% on room air. The neck is supple without any jugular venous distension or thyroid enlargement. The oropharynx is dry. Pupillary reflexes are intact. There is no obvious pallor or icterus. Lungs are clear to auscultation. Cardiovascular and gastrointestinal systems are unremarkable. On neurological examination, the patient is not very cooperative. She knows her name but disoriented to time and place. She can move all her extremities. Touch sensation are intact and deep tendon reflexes are symmetrical. On lab investigations, total and differential white count is normal. Her Hemoglobin and hematocrit are 12.3 g/dl and 36.5 respectively. Serum biochemistry shows Na:135 mEq/L, K : 3.6 mEq/L, Cl: 104mEq/L, Bi: 24 mEq/L, BUN: 30 mg/dl, glucose: 72 mg/dl and Ca: 10mg/dl. A CT scan of the head performed in the emergency department shows generalized cerebral atrophy. What is the most appropriate next step in the management of this patient? +
A 29 year old female is admitted to the hospital for an elective cesarean section. She is on her 38th week of pregnancy. The patient was diagnosed with type 1 diabetes three years ago. She is currently on NPH (32 units before breakfast, 26 units at bed time) and regular insulin ( 22 units before breakfast, 22 units before supper). Before admission her glucose control was acceptable and she denied hypoglycemic symptoms. She does not have any chronic diabetic complications. The procedure is scheduled on the next day of admission. Which statement correctly describes the proper preoperative management of diabetes in this patient? +
55 year old women came for a routine health check up and she was found to have abnormal lipid profile. Her TSH level is 11 µU/ml (normal is 0.35-5 µU/ml) and her free T4 is 1ng/dl (normal is 0.8-1.8 ng/dl). She is asymptomatic and taking no medications. Family history is positive for hypothyroidism in mother. Her two siblings are normal. She denies smoking, alcohol and drugs. Her menstrual cycles are normal. Examination is normal and CBC, metabolic profile and lipid profile are within normal limits. Which is best next step in this patient management? +
A 45 yr old is brought to the ED by his son. He was in his usual state this morning when he suddenly developed headaches, sweating and loss of consciousness. Physical examination shows a diaphoretic and comatose man. His fingerpick test show glucose of 45mg/dl. He regains consciousness after IV dextrose. He is then admitted to the hospital and recovers well on dextrose insulin infusion. He states that he is stressed out in his work and further investigation shows elevated serum insulin and C-peptide. Plasma insulin antibody is negative. What is the most probable cause for this episode? +
A 58 yr old postmenopausal woman comes to the clinic for weight gain for the past 2 years. She is a known diabetic and hypertensive on metformin, hydrochlorthiazide and atenolol. She also complaints of tiredness and weakness while climbing stairs and combing. Her weight is 200lbs, height is 5.2” inches, BP: 130/80, HR: 90/min. On physical examination, her extremities are thin when compared to the trunk and her face is round and plethoric. Her abdomen is distended with violaceous striae and there is mild proximal weakness of her lower extremities. Her 24 hr urinary cortisol is three times above the normal and high dose dexamethasone suppression test failed to lower the cortisol levels. Plasma ACTH levels are undetectable. What is the best next step in diagnosis? +
A 60 yr old woman is brought to the emergency department following a motor vehicle accident. She was hit by car from her side and claims that she did not see the car coming towards her. She had a past history of intraabdominal operation done 15 yrs ago for Cushing’s syndrome. Physical examination shows tanned female with normal vital signs. She has few abrasions on her face and chest. Her injuries are managed appropriately. What is the most likely diagnosis at this point? +
A 60 yr old woman is brought to the emergency department following a motor vehicle accident. She was hit by car from her side and claims that she did not see the car coming towards her. She had a past history of intraabdominal operation done 15 yrs ago for Cushing’s syndrome. Physical examination shows tanned female with normal vital signs. She has few abrasions on her face and chest. Her injuries are managed appropriately. What is the best next step in the management of this condition? +
A 40 yr old male is brought by his daughter to the ER with complaints of anorexia, nausea, vomiting, muscle cramps and weakness for the past two days. His daughter says he attended a party with his friend’s couple of days back. He is a known diabetic on regular oral hypoglycaemic drugs. On Physical examination his temperature is 36.7 C, blood pressure is 130/70 mmHg, pulse is 102/min and respiartions are 16/min. His oxygen saturation is 97% on room air. His fingerpick test show glucose of 110 mg/dl. On neurological examination, the patient is consious and cooperative. He knows his name and oriented to time and place. He can move all his extremities. Touch sensation are intact but deep tendon reflexes are sluggish. He is adequately hydrated and his EKG reveals prolonged PR and QT intervals. Serum chemistry shows Na:135 mEq/L, K: 3 mEq/L, Cl:104mEq/L, Bi: 24 mEq/L, BUN: 30 mg/dl, glucose:72 mg/dl, Mg:1mg/dl and Ca: 8mg/dl. What is the most appropriate way to manage this patient? +
A 20 yr old male was admitted to ICU following a motor vehicle accident. He sustained a cervical vertebrae translocation, which resulted in quadriplegia. He was put on ventilator and PEG tube. His vitals were normal and the patient was stabilized. After 2 weeks in ICU, his biochemical parameters shows a serum calcium of 12.8 mg/dl, a PTH level of 12pg/ml (N: 10-65pg/ml), a 25-hydroxyvitamin D level of 24mcg/ml (N 18-68 mcg/ml) and 1,25 dihydroxyvitamin D level of 15ng/L(N: 15-60ng/L). A repeat calcium level was 13.3mg/dl, with phosphorus level of 3.2mg/dl, albumin level 2.5 g/dl and ionized calcium level of 6.6mg/dl (N: 4-5.6mg/dl). What is the most likely cause of patient’s hypercalcemia? +
A 23 yr old male came to the emergency department with complaints of headache and palpitations. By time you attended the patient, he is asymptomatic. He reveals three similar episodes in the past that resolved spontaneously. He is currently on no medications and requests some pills to stop the episode because it is disturbing his preparation for exams. On examniation, you see a anxious and diaphorectic person in no acute distress. His temperature is 36.7 C, blood pressure is 130/70 mmHg, pulse is 102/min and respiartions are 16/min. Her oxygen saturation is 97% on room air. The neck is supple without any jugular venous distension or thyroid enlargement. The oropharynx is dry. Pupillary reflexes are intact. There is no obvious pallor or icterus. Lungs are clear to auscultation. Cardiovascular and gastrointestinal systems are unremarkable. During the prior visit in the ED for the similar episode his BP was 158/90mmHg. What is the most appropriate next step in the patient management? +
A 23 yr old male came to the emergency department with complaints of headache and palpitations. By time you attended the patient, he is asymptomatic. He reveals three similar episodes in the past that resolved spontaneously. He is currently on no medications. On examniation, you see a anxious and diaphorectic person in no acute distress. His temperature is 36.7 C, blood pressure is 130/70 mmHg, pulse is 102/min and respiartions are 16/min. Her oxygen saturation is 97% on room air. Other system examination was normal. A diagnosis of pheochromocytoma is confirmed after a positive test for 24-hour urine metanephrines and catecholamines. What is the next line of action for the patient. +
A 23 yr old male came to the emergency department with complaints of headache and palpitations. By time you attended the patient, he is asymptomatic. He reveals three similar episodes in the past that resolved spontaneously. A diagnosis of pheochromocytoma is confirmed after a positive test for 24-hour urine metanephrines and catecholamines. MRI of the abdomen shows an intraadrenal tumor. He was treated on phenoxybenzamine and beta-blockers sufficiently. The patient is appropriately prepared and is take for the procedure. During the procedure, the patient becomes hypotensive with dropping from120/80 to 80/50. Which is the appropriate treatement for the patient’s hypotension? +
A 26 year old male is brought to the ER with severe muscle pain especially in the thighs. He is an alcoholic and has been drinking heavily for the past 48 hours. He is a smoker and also uses marijuana and cocaine occasionally. He has no other significant medical history. His vitals are pulse 118/min, BP: 100/60 mmHg, RR: 22/min, Temp: 100F. Lungs are clear. Skin and mucus membranes are dry. There is generalized muscle tenderness and strength is decreased globally. You start to hydrate the patient with isotonic saline. EKG taken is normal. Urine analyses are pending. Patients laboratory testing shows the following:
Na: 147 mEq/L
K: 5 mEq/L
Chloride: 107 mEq/L
Bicarbonate: 18 mEq/L
BUN: 60 mg/dl
Creatinine: 2.3 mg/dl
Glucose:72 mg/dl
Ca: 8mg/dl
CK: 50,000 U/L
Which of the following the most appropriate course of action? +
A 73 year old male is in ICU on ventilator for three days after cardiac arrest. He had a past history of diabetes and CABG performed 7 years ago. Three days ago he collapsed at home, after which he was intubated and put on ventilator after prolonged hours of CPR in the hospital. Still he completely relies on ventilator support. He is unresponsive to verbal and painful stimuli. His vitals are BP: 110/60 mmHg, pulse 64/min and temperature is 99F. Which of the following doesn’t meet the prerequisite before considering the patient for the diagnosis of brain death? +
A 73 year old male is in ICU on ventilator for three days after cardiac arrest. Still he completely relies on ventilator support. He is unresponsive to verbal and painful stimuli. His vitals are BP: 110/60 mmHg, pulse 64/min and temperature is 99F. After discussing with the family, you plan to take him out of ventilator. You wanted to confirm the diagnosis of brain death with second test within a short observational time. Which of the following would you document to determine that the patient meets the criteria of brain death? +
A 16-year-old boy is brought to his physician's clinic by his father. Over the past several days, the patient has been increasingly fatigued and has noticed that the left side of his face has become paralyzed and less expressive. He denies any sick contacts or recent changes in mood, appetite, or weight. The patient states that he recently returned from a trip with the local boy scouts approximately 1 months ago. The patient explains that at first he saw a red lesion with a central clearing in his left lower extremity, but the lesion self-resolved without any intervention. In the clinic, neurological exam is significant only for unilateral weakness of the facial muscles on the left side. Further work-up, including CSF analysis, yields normal results. The physician then prescribes a pharmacologic agent to treat the patient's condition. What is the mechanism of action of the prescribed pharmacologic agent? +